Home and community-based Medicaid options for dependent older Floridians.

In an era of widespread state budget constraints, Florida has been increasingly challenged to provide long-term care services to a growing population of older dependent persons. The high costs of nursing home care have led the state to implement care management alternatives that offer potential for cost savings along with greater consumer satisfaction through maintenance of community residence. Although these alternative care approaches represent important opportunities to contain costs, it is equally important that professional care providers and policymakers understand how such programs operate. Here the Florida experience with eight home and community-based waiver models, in addition to the Program of All-Inclusive Care for the Elderly, are summarized and a comparative analysis offered that may enlighten the efforts of other states to establish cost-effective and attractive care management models.

Developing explicit positive beers criteria for preferred central nervous system medications in older adults.

BACKGROUND: The Beers criteria have been extensively used over the past decade to identify and evaluate potentially inappropriate medication use in adults 65 years of age and older in the United States. In contrast to the Beers criteria, the purpose of this pilot initiative was to develop a new set of explicit criteria for determining preferred (rather then potentially inappropriate) medications to use in older adults, using similar methodology as used in the three iterations of the Beers criteria. This initiative organized its evaluations around classes of medications that are both frequently used and associated with drug-related problems in older adults-central nervous system (CNS) medications. METHODS: This pilot study used a modified Delphi method-a set of procedures and methods for reaching group consensus for a subject matter in which precise information is lacking-to determine medications that are preferred for use in persons 65 years of age or older known to have specific medical conditions. Medications were selected as preferred because they are both effective, based upon a thorough evaluation of the clinical evidence, and pose less risk for older persons compared with alternative medications for the condition. Expert panelists evaluated 78 individual medications within four medical conditions (dementia, depression, Parkinson's disease, and psychosis). RESULTS: This study identified 13 preferred medications to be used in older adults with these conditions. CONCLUSIONS: This study expands explicit criteria to more precisely define preferred medication use in older adults. This refinement of the Beers criteria will enable providers to select medications with the greatest benefit-to-risk ratio for older adults, thereby minimizing drug-related problems. These criteria will need to be expanded to include other medication classes and medical conditions frequently encountered in older adults.

Discontinuing medications: a novel approach for revising the prescribing stage of the medication-use process.

Thousands of Americans are injured or die each year from adverse drug reactions, many of which are preventable. The burden of harm conveyed by the use of medications is a significant public health problem, and therefore, improving the medication-use process is a priority. Recent and ongoing efforts to improve the medication-use process have focused primarily on improving medication prescribing, and not much emphasis has been put on improving medication discontinuation. A formalized approach for rationally discontinuing medications is a necessary antecedent to improving medication safety and improving the nation's quality of care. This article proposes a conceptual framework for revising the prescribing stage of the medication-use process to include discontinuing medications. This framework has substantial practice and research implications, especially for the clinical care of older persons, who are particularly susceptible to the adverse effects of medications.

Health outcomes associated with potentially inappropriate medication use in older adults.

The purpose of this study was to examine the prevalence of potentially inappropriate medication use (PIMs) among community-dwelling older adults and the association between PIMs and health care outcomes. Participants were 17,971 individuals age 65 years and older. PIM use was defined by the Beers criteria. Drug-related problems (DRPs) were defined using ICD-9 codes. Forty percent of the 17,971 individuals filled at least 1 PIM prescription, and 13% filled 2 or more PIM prescriptions. Overall DRP prevalence among those with at least 1 PIM prescription was 14.3% compared to 4.7% in the non-PIM group (p < .001). In conclusion, preventing PIM use may be important for decreasing medication-related problems, which are increasingly being recognized as requiring an integrated interdisciplinary approach.

Propoxyphene use and risk for hip fractures in older adults.

BACKGROUND: Published guidelines have identified propoxyphene as an inappropriate medication for use in aged patients. It is no more effective than acetaminophen, yet has been associated with the same adverse effects (AEs) associated with other opioid drugs. In particular, its central nervous system-related AEs, dizziness and sedation, may increase the risk for fracture resulting from falls in older adults. Nonetheless, US studies have reported widespread use of propoxyphene in the elderly US population. OBJECTIVE: The aim of this study was to examine the risk for fracture associated with propoxyphene use in older adults. METHODS: This prospective cohort study used a large administrative claims data set from adults aged > or =65 years. A time-varying (lagged) covariate defined each person as a propoxyphene user or nonuser based on propoxyphene exposure in the 14 days before each fracture event in the cohort. Another time-varying measure stratified propoxyphene users based on their mean daily dose of propoxyphene (high dose = >260 mg; low dose = < or =260 mg of propoxyphene hydrochloride or equivalent napsylate salt). Time-dependent Cox regression models were used to estimate the association between propoxyphene exposure and occurrence of hip fracture (using International Classification of Diseases, Ninth Revision, Clinical Modification code 820.xx). RESULTS: A total of 362,503 patients were included in the analysis. During a mean follow-up of 464 days, approximately 10% (37,569) of the sample had > or =1 propoxyphene prescription filled and approximately l% (5065) sustained a hip fracture. Propoxyphene users had a 2-fold higher risk for hip fracture (hazard ratio [HR] [95% CI], 2.05 [1.87-2.25]) compared with nonusers of analgesics. Multivariate analysis found a dose-response relationship between propoxyphene and hip fracture risk (low dose, HR [95% CI], 1.45 [1.26-1.67]; high dose, HR [95% CI], 2.05 [1.85-2.29]). Other opioid analgesics were associated with an increased risk for hip fractures. CONCLUSIONS: The results of this cohort database study suggest that propoxyphene use among adults aged > or =65 years is associated with increased risk for hip fracture and suggest a need for interventions to reduce propoxyphene use in older adults. Clinicians should be aware of the risk for hip fracture with other opioids as well and weigh them against potential benefits when prescribing for older adults.

National trends in and predictors of propoxyphene use in community-dwelling older adults.

BACKGROUND: Several pain management guidelines and explicit medication-use criteria identify propoxyphene as an inappropriate medication for use in older adults. OBJECTIVE: This study was conducted to estimate trends in propoxyphene use among community-dwelling elderly (age > or = 65 years) Medicare beneficiaries from 1993 through 1999 and to determine whether beneficiaries' drug coverage and specific characteristics of their physicians were associated with receipt of propoxyphene in 1999. METHODS: Data from the Medicare Current Beneficiary Survey (MCBS) were used to examine the prevalence of propoxyphene use in cross-sections of nationally representative samples of community-dwelling elderly Medicare beneficiaries from 1993 through 1999. The 1999 MCBS was linked with the 1999 Area Resource File to examine patient and physician factors associated with propoxyphene use in the community-dwelling elderly at the county level. RESULTS: Rates of propoxyphene use were generally stable over the 7-year period, from an annual prevalence of 6.8% in 1993 to the slightly decreased prevalence of 6.6% in 1999. No protective effects against propoxyphene use were observed based on beneficiaries' drug coverage or type of drug coverage. Rather, Medicaid beneficiaries were more likely to receive propoxyphene than those without drug coverage (odds ratio [OR] = 1.40; 95% CI, 1.02-1.92). Among physician characteristics, male sex (OR = 1.34; 95% CI, 1.02-1.75) and medical specialty (OR = 0.81; 95% CI, 0.65-1.00) were strongly correlated with prescribing of propoxyphene. CONCLUSION: This study found a continuing high prevalence of propoxyphene use in the community-dwelling elderly Medicare population from 1993 through 1999, with > 2 million beneficiaries receiving the drug in 1999.

The class effect: is it relevant to geriatrics?

The formulary of medications available today provides a remarkable range of choices to all prescribers and their patients. In some ways, choices have become easier to make, whereas in other ways, choosing has become a nightmare of dueling considerations. One approach to simplification has relied on class effect. The hypothesis is that drugs within a pharmacological class all work similarly, have similar advantages and disadvantages, and are-to a large extent-interchangeable. If one develops familiarity with one or two agents in a class, that is all one needs to know, because there is little difference between agents within a drug class. The question is whether this approach based on class effect is relevant to geriatrics.

Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts.

BACKGROUND: Medication toxic effects and drug-related problems can have profound medical and safety consequences for older adults and economically affect the health care system. The purpose of this initiative was to revise and update the Beers criteria for potentially inappropriate medication use in adults 65 years and older in the United States. METHODS: This study used a modified Delphi method, a set of procedures and methods for formulating a group judgment for a subject matter in which precise information is lacking. The criteria reviewed covered 2 types of statements: (1) medications or medication classes that should generally be avoided in persons 65 years or older because they are either ineffective or they pose unnecessarily high risk for older persons and a safer alternative is available and (2) medications that should not be used in older persons known to have specific medical conditions. RESULTS: This study identified 48 individual medications or classes of medications to avoid in older adults and their potential concerns and 20 diseases/conditions and medications to be avoided in older adults with these conditions. Of these potentially inappropriate drugs, 66 were considered by the panel to have adverse outcomes of high severity. CONCLUSIONS: This study is an important update of previously established criteria that have been widely used and cited. The application of the Beers criteria and other tools for identifying potentially inappropriate medication use will continue to enable providers to plan interventions for decreasing both drug-related costs and overall costs and thus minimize drug-related problems.

Trends in the prescription of inappropriate drugs for the elderly between 1995 and 1999.

BACKGROUND: Using criteria developed by Beers et al between 1991 and 1997, previous studies have reported high levels of inappropriate drug prescribing for community-dwelling elderly patients (age>or=65 years). However, it is not known whether the Beers criteria have had a beneficial effect on prescribing practices. OBJECTIVES: The aims of this study were to compare the prevalence of potentially inappropriate drug use (based on the Beers list) among older Americans between 1995 and 1999; to determine whether any decreases in such use were more likely to be the result of improved adherence to guidelines or of replacement of older medications by newer drugs; and to examine individual characteristics that place elderly patients at increased risk for inappropriate drug use. METHODS: This was a panel study involving nationally representative samples of community-dwelling elderly persons from the 1995 and 1999 Medicare Current Beneficiary Surveys (MCBS). For comparison, data were analyzed from samples of disabled Medicare beneficiaries aged <65 years for the same periods. The samples were assessed for the use of 36 individual drugs, drug classes, and combinations carrying a risk for adverse out comes in the elderly based on the 1997 Beers criteria for drugs to be avoided in this population. RESULTS: The study samples contained 7628 community-dwelling elderly persons from the 1995 MCBS and 8902 from the 1999 MCBS, and 1863 and 1851 disabled Medicare beneficiaries aged <65 years for the respective survey years. The proportion of elderly patients taking >or=1 drug on the Beers list declined from 24.8% in 1995 to 21.3% in 1999 (P<0.05). There was a nonsignificant increase in the proportion of disabled Medicare beneficiaries taking >or=1 drug on the Beers list from 31.1% in 1995 to 31.5% in 1999. CONCLUSIONS: There was a significant decline in the use of potentially inappropriate drugs by elderly patients between 1995 and 1999, particularly in the use of those drugs linked to the most severe outcomes. However, approximately 7 million elderly patients still received potentially inappropriate drugs in 1999, underscoring the continued need for effective interventions to improve prescribing for this vulnerable population.

The Merck Manual of Geriatrics

It provides information on geriatric care, related to falls, fractures and injuries, surgery and rehabilitation, psychiatric disorders, delirium and dementia, neurologic, musculoskeletal, metabolic, endocrine, hematologic, pulmonary , cardiovascular, kidney, urinary tract, gastrointestinal, dermatologic and sensory organ disorders, cancer, men's and women's health, and infectious diseases.

The Merck Manual of Diagnosis and Therapy

It covers all the subjects on internal medicine as well as detailed information on pediatrics, psychiatry, obstetrics, gynecology, dermatology, pharmacology, ophthalmology, otolaryngology, and a number of special subjects, and quickly provides information that helps practitioners achieve optimal care.